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Conservation measures during national drug shortages in 2018: a case series of 200 women receiving isobaric bupivacaine for cesarean delivery
Abstract Number: T2D-450
Abstract Type: Original Research
In early 2018, critical shortages of bupivacaine affected obstetric anesthesia practice in an unprecedented way. Centers reported dwindling supplies and no availability of hyperbaric 0.75% bupivacaine (HBB), whether in spinal kits or in batches. After a reviewing options, isobaric bupivacaine 0.5% (IBB) was identified as best alternative for HBB. Studies of IBB versus HBB for cesarean delivery (CD) did not identify differences in level of block, need for vasopressors, side effects, or failure of block.(1,2) Based on the SOAP advisory3 and discussions with our Pharmacy leadership to assess the available inventory, it was decided that daily aliquoting by Pharmacy of IBB 0.5% syringes (15mg/3ml) for spinal anesthesia for CD would be the best solution for our L&D unit.
Our division members were informed (1) conservation measures were indispensable for the next 4-6 months, (2) IBB (12-15mg with neuraxial opioids per usual standard) was to be used for non-emergent or straightforward cases, (3) HBB would be reserved for emergent or complex cases. A case report form (CRF) evaluating onset time (min), delay in skin incision time, high dermatomal block, significant hypotension despite immediate start of phenylephrine infusion, maternal tachycardia, and conversion to GA was completed for all cases with IBB or HBB. CRFs was reviewed weekly to identify major complications and provide feedback related to IBB use. Subjective concerns with IBB vs HBB were also gathered.
IBB was used between Feb 14- June 15 2018; 246 CRFs were collected representing 95% of cases done under spinal anesthesia during the shortage period. IBB was used in 200 cases, which far exceeded the available supply of over that period, and 46 cases received HBB.
With IBB, delayed onset (>12 min resulting in skin incision being delayed ) occurred in 25 cases (12.5%), failure of surgical block requiring a 2nd neuraxial procedure occurred in 4 cases (2%), significant hypotension (SBP < 65mmHg) occurred in 7 cases (3.5%) with one patient requiring transient mask ventilation for high spinal , prolonged maternal tachycardia (>150bpm) in 2 cases, and urgent CD were done in a timely fashion with IBB in 2 cases. With HBB (urgent cases by definition), a longer than acceptable onset (>10 minutes) occurred in 6 cases (13%) with 1 requiring conversion to GA (STAT CD for abruption). There was significant hypotension (SBP <65mmHg) in 1 case (2.1%).
While this conservation measure allowed us to maintain our usual practice of providing neuraxial anesthesia for over 95% of all CD with only 1 case converted to GA, perception was that using IBB provided less reliable surgical block (longer onset, higher block, hemodynamic instability) and all were happy to resume to usual care mid-June.
1. Anaesthesia 2018;73:790-1.
2. Anaesthesia 2018;73:499-511.